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STATEMENT OF MORTGAGE OR CONTRACT INDEBTEDNESS
FOR DEDUCTION FROM ASSESSED VALUATION
State Fwm 43709 (RS / 4-03) "
PrescriDed by Department of Lotal Govemment Finance
INSTRUCTIONS:
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Coun Township Year
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� �� � File Mark
To be filed in person or by mail with the County Auditor of [he counry where the property is4ocated. S POO4
Filing Dates: 1) Real Property: During the 12 months be%re May 11 0/ the year the deduction is to be effective.
2) Mo6ile Homes assessed under IC 6-1.1-7: Belween January 15 and/ �M..arch 2 �of the yeai the deduction is lo be eflective.
See reverse side for additional instructions and qualifications. /.' ,G„� .`^,l"� 7�-���
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Applicant (ow orcontract buyer- ee restnctions on rev se ide)
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Taxing Di Key nu ber / legal desu,iPtion Record number .
�_��0� 9— Q/ !/1 � 9 Q� Page number ��7/
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Assessed value of real property as of MoAgage / Contrad indebtedness unpaid as of Is the applicant the sole legal or equitabie-
March 1, current year March 1, current year owneR ❑ Yes � No
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Ii no, what is his / her exad share of interest? If owned with someone other lhan spouse, indicate with whom.
If name on record is different than that of applicanf, indicate below: Is the property in question:
❑ Real Property p Modle Hm�e QC Cr1.1-�
�me of mortgagee or contraIX seller -
Address of mortgagee or contract seller (number and street, ci , tate, ZIP
Name of assignee or other owner or holder of mortgage
Address of assignee (number and sVeet, city, state, ZIP code)
Does appliwnt own property in�any other If yes, what county? What Taxing Distric[? Has this�dedudion�been requested on
county in Indiana? property for current yeaR � Yes ❑ No
COUNTY AUDITOR
Deduction approved in the amount of:
20 20 20�_ 20 0� 20 20 20
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Signature County Audftor Date
/ We certity under the penalty of perjury that the above and foregoing infortnation is true and corred and that the applicants was / were
sident of Indiana and owner of ihe aforementioned property on March 1, 20
Signatu (owner's full name) Person authorized by duty executed Power of Attomey
.�� or by IC 6-1.1-12-.07
u ident address of applicant �R�,�,',���� Address of authorized person
�Il l � / �NT/�,� ST. �i76 %D
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